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%... SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209)468-3433 Web:www.sjgov.org/ehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: V r f Page of Facility Addre s: \ /1 n City; Insp�on/D/ . a � S'�3 0 0 /l f\ ��JILs, FA#: PR#: t.� Program Element: 6- ! -2. Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21,320 gallons in tanks'and containers". Complete one box for each tank or each cumulative container product type. ❑ Tank (2820) IQ Containers (2821) #of Containers: TA# 1Produc'tType: M4:3'TO Total Capacity: S-1 gallons (per tank or cumulative for containers by product type) Install Date: El Tank (2820) Vcontainers (2821) #of Containers: �_ TA#: 2 Total Capacity: -51 gallons Type: Y LC' Z t (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: TA#: 3 Total Capacity: gallons Product Type: G f-(W- V I �' (per tank or cumulative for contai ers by product type) Install Date: ❑ Tank (2820) Containers (2821) #of Containers: �_ TA#: 4 Total Capacity: S'5- gallons Product Type: Am czg: C71 L (per tank or cumulative for containers by product type) Install Date: ❑ Tank (2820) ❑ Containers (2821) #of Containers: TA#: 5 Total Capacity: gallons Product Type: (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: 'z- Z gallons Total Capacity for Site: gallons Comments: = Z7,3, ra /3 7.0 EHD Inspector Reviewed II Date: Entered Date: By Initial: �y/f�l t_ �b,p°I By Initial: `Aboveground storage tank means a tank that has the capacity to store 55 \gallons or more of petroleum. '"Container means a storage device designed to be moved when full. EHD 28-01 AST SURVEY FORM 09/12/08